2. 2
UTILIZATION OF
INVENTORY
Maximum utilization of dressing product and
techniques that readily available – THE OLD
ARMY
KNOWLEDGE
Getting appropriate knowledge to ensure and
enhance clinical practice based by current
evidence
MODERN DRESSING
Selection of appropriate modern dressing
– THE NEW ARMY
WOUND MEDICINE PRACTICE
3. 3
01
02
03
04
Introduction
The Old Army –What's
Common In Our Setting?
Mechanism Of
Action
Effectiveness &
Cytotoxicity To Wound
Healing
05. THE NEW ARMY
OUTLINE
4. 4
The Old Army (Conventional
Dressing)
A 45 minutes learning session on conventional dressing
readily available within Ministry of Health Malaysia –
namely – Chlorhexidine, Povidone Iodine (PVP-I),
KMNO4 solution, Hydrogen Peroxide (H2O2), Silver
preparation, Spirit, Alcohol and Flavin Solution
“But time growing old teaches all things…” – Aeschylus
5. 5
CHLORHEXIDINE
01 HYDROGEN
PEROXIDE02 KMNO4
03
PVP - IODINE
04 ACETIC ACID
05 SILVER
SULFADIAZINE06
THE OLD ARMY – What’s Common in Our
Setting?
4%, 5% 3% 1 : 1000/5000
1%0.25%, 0.5%7 - 10%
ALCOHOL
07 METHYLATED
SPIRIT08 ACRIFLAVINE
SOLUTION09 0.1%96%70%
7. 7
01
CHLORHEXIDINE
T H E O L D A R M Y
• BIGUANIDES group, C22H30Cl2N10 ,
• BACTERICIDAL (against Gram-positive and Gram-negative
organisms, facultative anaerobes, aerobes, and yeasts).
Ineffective for polio and adenovirus
• Used in dentistry, urology, gynecology, wound healing
• Time of onset: 30 seconds
8. 8
• Unsure prolonged exposure for
carcinogenesis, recommended stop use
after 6 months
• Anaphylactic reaction
Side Effect
Positive charge cation CHX binds with
negative charge bacteria cell wall to
induce lysis
Mechanism of Action
9. 9
Efficacy
• Safe for wound irrigation in low concentration
• Not severely effect healing time (no effect on
collagen production or tensile strength of
wound)
Cytotoxicity
• Increased resistant to microbes and
cytotoxicity compared to OCT & PHMB
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( C H L O R H E X I D I N E 4 , 5 % )
10. 10
02
HYDROGEN
PEROXIDE
T H E O L D A R M Y
• PEROXYGENS group, H2O2
• Bacteriostatic (sporicidal at 0.88 mol/L, poor bactericidal),
broad spectrum > g+ve
• Dental mouthwash, acute wound minor cuts, cosmetic
• Reaction time: immediate
11. 11
H202 Mode of Action
The production of free hydroxyl radicals in the
Fenton reaction is thought to be the basis of
biocidal actions of hydrogen peroxide. Free radicals
eventually lead to oxidative damage proteins and
membrane lipids in vivo. The oxidizing radical as
the ferryl radical induces DNA oxidation
T H E O L D A R M Y
12. 12
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( H 2 O 2 3 % )
Efficacy
• No negative effect on wound healing but not
reduce bacterial effect
• Effervescence of hydrogen peroxide provide
some mechanical benefit in loosening debris
and necrotic tissue of the wound
Cytotoxicity
• No retardation of re-
epithelialization
13. 13
03
KMnO4
T H E O L D A R M Y
• Dye, manganese oxidizing effect – purple crystals with sweet taste
• Low Bactericidal effect – broad spectrum
• Initially used to suppress vesicular stage of eczema- dermatitis
• Reaction time: required 1hr for bactericidal effect
14. 14
Mechanism of Action
As an astringent that suppress inflammation process
POTASSIUM PERMANGANATE
T H E O L D A R M Y
15. 15
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( K M N O 4 1 : 5 0 0 0 , 1 : 1 0 0 0 0 )
Efficacy
• Effective bactericidal in 1:10000
Cytotoxicity
• Fatal over 4oz consumed
• Burns and stain the skin
• Combustible – mixture with acetic acid might
explode
• Tablet should be dissolved completely –
might cause cutaneous necrosis
• Most centre has obsolete this prep d.t
manganese toxicity – nephrotoxin,
hepatotoxin – should be used only on
superficial wound
16. 16
04
PVP - IODINE
T H E O L D A R M Y
• HALOGEN RELEASING group, polyvinylpyrrolidone iodine,
C6H9NO
• Bacteria do not develop resistance to PVP-I
• Bactericidal – broad spectrum
• Usage: antiseptic for prevention and treatment wound infection
17. 17
Iodine is highly reactive with surrounding and has strong oxidizing effect on functional groups of amino acids (-NH 2, -SH etc.), Nucleotides, and fatty acids (double
bond of unsaturated fatty acids). Interaction of Iodine with these groups in a cell results in disintegration of the cytoplasm, enzyme denaturation, loss of integrity in the
bacterial cell membrane and fungal cell wall
18. 18
Efficacy
• Effective in reducing bacterial load in
wound – effect not persist - lasted for
4 days
Cytotoxicity
• No inhibition in wound re-
epithelialization
• Concentration dependent – not
suitable for burns
• Systemic toxicity
Contraindication
• 1. Hypersensitivity to Povidone iodine and other preparations
containing iodine
• 2. Thyroid disorders - goiter, hypothyroidism
• 3. Application to large areas of skin
• 4. Patient on Lithium therapy
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( P V P - I 7 , 1 0 % )
19. 19
05
ACETIC ACID
T H E O L D A R M Y
• PEROXYGENS group, C2H4O2
• Bactericidal , broad spectrum esp. pseudomonas
• Dental formulation, wound antisepsis
• Reaction time: N/A, short duration of action about 1hr, require
repeated dosing
20. 20
Undissociated acetic acid may enhance lipid solubility allowing increased fatty acid accumulation on the cell membrane or in other cell wall
structures. As a weak acid it will inhibit carbohydrate metabolism resulting in subsequent cell death.
Acetic Acid MOA
21. 21
Efficacy
• Efficacious against
pseudomonas, but not
significantly
Cytotoxicity
• Beware of phenylketonuria due to ketone
intermediates
• No delay in reepithelialization
• Does not shown to influence tensile
strength
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( AC E T I C AC I D 0 . 2 5 , 0 . 5 % )
22. 22
06
SILVER
SULFADIAZINE
T H E O L D A R M Y
• Topical antimicrobial – partial to full thickness burns
• Bactericidal – broad spectrum
• Evidence showed that antibiotic are more potent therefore no
more generally recommended
• C10H9AgN4O2S
• Oligodynamic effect to bacteria, fungi and algae
23. 23
MECHANISM OF ACTION
Interact with sodium chloride containing body fluid,
silver ions released – ionized Ag+ catalyze the
formation of disulfide bonds lead to protein structural
changes of bacterial wall
SILVER
SULFADIAZINE
THEOLDARMY
24. 24
Efficacy
• Insufficient evidence whether silver-containing dressing or
topical agents promote wound healing or prevent infection
(Cochrane R)
Cytotoxicity
• Delay wound healing by sloughing mechanism
• no more recommended to burns wound due to altered
appearance and frequent re-application
• Not to be used along with proteases (inhibited by silver
ions)
Precaution
• Itching and pain
• Low WBC count, allergic reaction, red blood cell breakdown,
liver inflammation
• Allergic to sulfonamides
• Not to be used less than two months children
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( S I LV E R S U L FAD I AZ I N E 1 % )
25. 25
07
ALCOHOL
T H E O L D A R M Y
• Ethyl, Isopropanol, C3H8O
• Bactericidal and fungicidal, broad spectrum
• Most commonly used as rubbing
• Reaction onset: immediate
27. 27
EFFICACY
• No information available for open wound –
burns effect
• Hand rubbing better than hand wash
CYTOTOXICITY
• Depends on the type of alcohol methyl >
isopropyl > ethyl
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( AL C O H O L , 7 0 % )
30. 30
09
ACRIFLAVINE
SOLUTION
T H E O L D A R M Y
• DYE group, acriflavinium chloride, C14H14ClN3
• Commercial preparations are often mixtures with proflavine
• Bacteriostatic to g+ve
• Undergo testing as antimalarial drugs, used in biochemistry for
fluorescently labeling high molecular weight RNA, fungal infection
treatment for fish aquarium
31. 31
ACRIFLAVINE
T H E O L D A R M Y
Proflavine acts by interchelating DNA (intercalation), thereby
disrupting DNA synthesis and leading to high levels of mutation in
the copied DNA strands. This prevents bacterial reproduction
32. 32
Efficacy
• In an animal model, acriflavine has been
shown to inhibit HIF-1, which prevents blood
vessels growing to supply tumors with blood
and interferes with glucose uptake and use
Cytotoxicity
• Proflavine is toxic and carcinogenic in
mammals and so it is used only as a surface
disinfectant or for treating superficial wounds
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( AC R I F L AV I N E 0 . 1 % )
33. 33
WOUND AT RISK (WAR)
SCORE
T H E O L D A R M Y
If the WAR Score reaches or exceeds 3 points, an antiseptic
treatment is justified.
35. 35
( A ) A gauze dressing adhering to the wound. ( B ) A foam dressing, one of the interactive dressing
products. In comparison with a gauze dressing, a foam dressing has many advantages
MOISTURE ENVIRONMENT
39. 39
CONCLUSION
01
02
03
KNOWLEDGE
Adequate knowledge of conventional and
modern dressing material is compulsory
UTILIZATION OF
INVENTORY
Having fully utilized current existed dressing
material is vital especially for poor resources
clinic
APPROPRIATE SELECTION
OF WOUND DRESSING
PRODUCTBased on net knowledge and inventory
At physiologic pH, chlorhexidine salts dissociate and release the positively charged chlorhexidine cation. The bactericidal effect is a result of the binding of this cationic molecule to negatively charged bacterial cell walls. At low concentrations of chlorhexidine, this results in a bacteriostatic effect; at high concentrations, membrane disruption results in cell death
Whether prolonged exposure over many years may have carcinogenic potential is still not clear. The Federal Drug Administration (FDA) in the USA recommendation is to limit the use of a chlorhexidine gluconate mouthwash to a maximum of six months
Povidone iodine is an iodophore antiseptic and is a microbicidal drug. It releases iodine from its complex and produces pharmacological actions. The released iodine produces antiseptic actions. Iodine is highly reactive with surrounding and has strong oxidizing effect on functional groups of amino acids (-NH 2, -SH etc.), Nucleotides, and fatty acids (double bond of unsaturated fatty acids). Interaction of Iodine with these groups in a cell results in disintegration of the cytoplasm, enzyme denaturation, loss of integrity in the bacterial cell membrane and fungal cell wall .These will leads to destruction of microbial protein and DNA and finally kills the microbes.